Application for C Plus Medicare Select Plans An Independent Licensee of the Blue Cross and Blue Shield Association Application for Medicare Select Plan B or Plan F Be sure to choose which Medicare Select Plan you are applying for. PLEASE NOTE: Individuals who are receiving medical assistance benefits from the Medicaid Agency, such as regular Medicaid or QMB benefits, are not eligible to purchase C Plus Medicare Select Plans or any other Medicare supplement. Individuals who are under the age of 65 and have Medicare due to End Stage Renal Disease (ESRD) may not be eligible to purchase C Plus plans. Be sure to read the important disclosures listed on the back before completing this application. Please use black ink and print clearly. Keep the bottom copy for your records. Mail the top copy in the return envelope which is included in your C Plus packet, or send to: Blue Cross and Blue Shield of Alabama Attention: C Plus Applications P.O. Box 11551 Birmingham, Alabama 35282-9722 Blue Cross and Blue Shield of Alabama Insurance Resource Center: 1-877-278-7007 For faster processing of your application, apply online at www.bcbsalmedicare.com. BCAEA001
PERSONAL INFORMATION LAST NAME * MAIDEN/MIDDLE NAME SOCIAL SECURITY NUMBER * ADDRESS * CITY * DATE OF BIRTH (MM/DD/YYYY) * E-MAIL ADDRESS (Optional) MEDICARE INFORMATION You must have Medicare hospital (Part A) and medical (Part B) coverage to enroll in a C Plus plan. Please copy your information from your red, white and blue Medicare Card onto the card on the right. ELIGIBILITY INFORMATION FOR OFFICE USE ONLY Representative Code #1: DR. MR. MRS. MS. PLEASE PRINT USING UPPERCASE LETTERS: (USE BLACK BALL POINT PEN - PRESS FIRMLY) FIRST NAME * PHONE NUMBER HOME WORK CELL Representative Code #2: SUFFIX (JUNIOR, SENIOR) * INDICATES REQUIRED FIELDS HEALTH MALE STATE * ZIP * SOCIAL SECURITY ACT CLAIM NUMBER FEMALE INSURANCE EFFECTIVE DATE If you lost or are losing other health insurance coverage and HOSPITAL PART A received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement MEDICAL PART B insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS. Please mark Yes or No with an X. 1. Do you have the original Medicare Plan the traditional Medicare plan offered by the federal government that lets you go to any healthcare provider who accepts Medicare? Yes No 2. If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example: a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan, leave END blank. START / / END / / Please attach your disenrollment letter which shows the disenrollment date from that plan. a. If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare supplement policy? Yes No b. Was this your first time in this type of Medicare plan? Yes No c. Did you drop a Medicare supplement policy to enroll in the Medicare plan? Yes No BLUE CROSS AND BLUE SHIELD COPY SALES COPY APPLICANT COPY PAGE 1
TO THE BEST OF YOUR KNOWLEDGE: 1. a. Did you turn 65 in the last six (6) months? Yes No b. Did you enroll in Medicare Part B in the last six (6) months? Yes No c. If yes, what is the effective date? 2. Are you now entitled to Medicare as a result of disability? Yes No 3. a. Do you have kidney failure, chronic renal disease or ESRD (End Stage Renal Disease)? Yes No b. If you have been diagnosed with ESRD, have you had a kidney transplant in the last 36 months? Yes No c. If yes, what is the transplant date? 4. a. Do you have another Medicare supplement policy in force? Yes No b. If so, with what company and what plan do you have? Company Plan # c. If so, do you intend to replace your current Medicare supplement policy with this policy? Yes No 5. Have you had coverage under any other health insurance within the past 63 days (for example: an employer, union, or individual plan)? Yes No a. If so, with what company and what kind of policy? Company Policy # b. What are your dates of coverage under the other policy? If you are still covered under the other policy, leave END blank. START / / END / / 6. Are you covered for medical assistance through the state Medicaid program? Note to Applicant: If you are participating in a Spend-Down Program and have not met your Share of Cost, please answer NO to this question. Yes No If yes, a. Will Medicaid pay your premiums for this Medicare supplement policy? Yes No b. Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium? Yes No c. Are you presently living in a nursing home? Yes No d. Are you enrolled in the Medicaid Nursing Home Program which provides an increase in your maximum monthly income to pay premiums for supplemental coverage? Yes No 7. Are you a resident of the state of Alabama? Yes No C PLUS PLAN SELECTION Please select one C Plus plan. Failure to choose a C Plus plan will delay the processing of your application. See your Outline of Medicare Supplement Coverage prior to making your selection. YOU MUST SELECT ONLY ONE PLAN: PLAN B PLAN F BLUE CROSS AND BLUE SHIELD COPY SALES COPY APPLICANT COPY PAGE 2
CHOOSE YOUR EFFECTIVE DATE AND PAYMENT TYPE MONTH DAY YEAR 0 1 1. Request an effective date. This is the date your C Plus plan becomes effective. It may not be earlier than the date this application is received by us and must be effective on the first day of the requested month. 2. Select ONE payment method. Failure to choose a payment method will delay the processing of your application. Premiums are payable in advance on a monthly basis. We will accept your premium payments only if they are made from your personal (non-business) account. E-CHECK, DEBIT OR CREDIT CARD Complete and mail the enclosed Automatic Payment Authorization Agreement with your preferred payment method. For e-check only, include a blank voided check. If approved, your payment will be charged to your account. Notification will be sent to the e-mail address you provided on this application when premium is due. BILL ME LATER BY E-STATEMENT You will receive an e-mail notification each month when your billing statement is available. A valid e-mail address is required. Please provide your e-mail address in the space provided on page 1 of this application. BILL ME LATER BY MAILED BILLING STATEMENT You will mailed a billing statement each month which includes an invoice to return with your premium payment. IMPORTANT: MEMBERSHIP AGREEMENT PLEASE READ AND SIGN PLEASE READ THE FOLLOWING INFORMATION CAREFULLY: I am applying for the C Plus plan I selected on page 2. If you accept this application, you will send me an identification card. I understand that acceptance of this application is subject to my answers to all questions. I also understand that this application and the Contract, including all amendments, make up my entire contract with you. If my premiums are deducted from my pay, I authorize my employer, if applicable, to deduct the amount of premiums (or the part I pay) and send them to you. If you do not accept my application, the only thing you have to do is to return any premiums I paid. You may pay providers directly for services to me. I ask my doctor, hospital, Medicare or anyone else to give all medical records of me to you. You may release those records to anyone necessary in order to administer the contract. This begins now and continues as long as you need to decide about this application and process any of my claims. I will cooperate with you if you need information about other health policies I have, including payments by them, and I will give it to you. If you need information to help you subrogate (substitute for me or a family member) or be reimbursed, I will give it to you. I understand that this policy I selected above is a Medicare supplement plan and certify by my signature below that I am eligible for and enrolled in Parts A and B of Medicare. I understand and agree that Blue Cross and Blue Shield of Alabama engages in substantial interstate activity affecting interstate commerce, that this agreement itself affects interstate commerce, and that, therefore, any disagreement between us must be submitted to binding arbitration in accordance with the terms of the contract. ACKNOWLEDGEMENT OF RECEIPT: OUTLINE OF MEDICARE SUPPLEMENT COVERAGE The undersigned hereby acknowledges that he/she has been given (i) the Outline of Medicare Supplement Coverage (ii) a description of the network providers and financial consequences of using non-network providers, (iii) a description of coverage for emergency and out of area services, and (iv) a description of the quality assurance and grievance procedure under the policy. ARBITRATION THE CONTRACT YOU ARE APPLYING FOR INCLUDES BINDING ARBITRATION. THIS MEANS ANY DISAGREEMENT WILL BE SETTLED BY ARBITRATION NOT A COURT. THE ARBITRATOR S DECISION IS FINAL AND BINDING. AN ARBITRATOR IS AN INDEPENDENT, NEUTRAL PARTY WHO MAKES A DECISION AFTER LISTENING TO BOTH PARTIES. THIS DECISION CAN NOT BE REVIEWED BY A COURT; THE ARBITRATOR ACTS AS JUDGE AND JURY. BY SIGNING BELOW YOU AGREE TO SETTLE ANY DISAGREEMENT BY ARBITRATION INSTEAD OF A COURT TRIAL. AGREEMENT TO ARBITRATE AFTER READING THIS, I AGREE TO THE ARBITRATION PROVISIONS IN THE CONTRACT. YOUR SIGNATURE DATE SIGNED This application is not complete unless it is signed and dated. The application MUST be fully completed before we may determine your eligibility. BLUE CROSS AND BLUE SHIELD COPY SALES COPY APPLICANT COPY PAGE 3
THE FOLLOWING INFORMATION IS REQUIRED BY FEDERAL REGULATIONS Please be aware that: 1. You do not need more than one Medicare supplement policy. 2. If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages. 3. You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy. 4. If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension. 5. If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or union-based group health plan. If the Medicare supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension. 6. Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).